I started in healthcare in 1989 with CIS Technologies in Tulsa, OK. At this time, hospitals were sending tapes to payers each day for payment. Soon, the tapes were replaced with digital transactions and CIS went from a $1M business to $50M in 1996.

The goal of RCM is to get paid what you are owed as quickly as possible. That has not changed. As one of my early clients stated, “No payment, no mission.”

RCM problems persist. Payer rules are more complex than they were 30 years ago. Healthcare organizations need to be more vigilant than ever to ensure they are getting paid properly. Contracts are also more complicated.

Many RCM companies have grown through acquisition, and this has created a patchwork of disparate systems and many healthcare organizations have purchased systems from multiple vendors, making integration key to handing data from front end to mid to the back end of the revenue cycle.

Likely the most important step occurs up front in scheduling and registration. If the demographic data or insurance information is incorrect, there are implications to downstream processes. At any point, if the process breaks down, all downstream workflows (and even data) can be affected.

Gaps in data, complex and changing payer rules and contract changes that create variability between payers further complicate the revenue cycle. Payments may be consistent with contract terms. Failure to have good bad debt policies and regular monitoring may result in increased write- offs. Players may have out of network and other limitations. Payers are also increasing the number of denials, and this is forcing some healthcare organizations to outsource denial management and other RCM processes.

Now that patients are becoming a significant revenue source, the business side of caring has grown in importance. If patients have a good clinical experience and the desired outcome is achieved, all this good work can be undone if they have a bad billing and collection experience. The no surprises law and the need to create accurate estimates for services illustrate the importance of the consumerism trend.

Whether technology used personal computers, servers or is cloud hosted, it is key that solutions are being used. If they are only being used 20 – 30% of the time, you are missing out on key capabilities to grow your business and reduce operational expenses. Track utilization of your solutions. If something isn’t being used, ask why. You cannot get value from something that is not in use.

Skilled nursing and acute care are more similar than they are different. Both have incredible dependencies on the front end of the revenue cycle. Like most industries, if garbage data goes in, garbage data comes out – and it needs to be cleaned up before it’s useful.

Unlike acute, skilled facilities can select the patients they admit. There is up front due diligence on every prospective resident. SNFs evaluate the medications prospective residents need and any special care considerations before granting them admission. From a financial perspective, new residents can pay from a number of sources. Some have insurance and personal savings as well as other assets that pay for their care. If these funds are exhausted, residents turn to Medicare to assume payment.

Hospital emergency departments, on the other hand, must take everyone. Patients who present to the ED must be stabilized before transferring to another setting of care. There is no due diligence process and even establishing the identity of some patients can be challenging, let alone determining insurance coverage. In emergency situations, care may need to be rendered before insurance coverage can be determined, whether a patient is in-network or out, and before prior authorization secured. Each of these factors affect the revenue cycle and together they make for a very complicated account.

As healthcare moves toward value-based care, it will be even more important to deeply understand the revenue cycle. Routine transparency to KPIs will be insufficient. Having the capability to drill down into data allows you to fully understand trends. For example, you will need to answer questions such as the following.

In 2021, PointClickCare launched an RCM services business that offered end-to-end RCM capabilities for SNFs. We became an extension of the central business office (CBO). The RCM team was no long right down the hall. We were remote. Luckily the pandemic neutralized this factor.

Since most SNFs are for profit, there is a lot of merger and acquisition activity in the industry. Sometimes it is only one facility and other transactions are much larger. Regardless of the size, the acquiring company needs a portfolio level view of their RCM performance. As their outsourcing partner, so do we. The transparency to the various RCM workstreams that we receive from WhiteSpace Health is invaluable to us and our SNF clients.

WhiteSpace Health has deep RCM and healthcare experience and that is reflected in their platform. They were able to get us live quickly and they continue to turn around our requests. And, of course, having the data in a robust SaaS platform is an absolute most for us.

Being able to stand up a solution quickly was an important consideration. We needed to fully use our data and get reports specifically built for the SNF business. Because WhiteSpace Health already had a deep knowledge of the revenue cycle, we were able to collaborate on requirements and have them turned around quickly.

Since our services business is based on a contingency of collecting cash, it is paramount that we collect cash quickly and that the full amount is also collected to optimize our revenue.

We considered building an analytics solution in-house. However, we discovered that it would take more time to do that than we wanted to spend. In the time it would take to build our own product, the market could dramatically change, and we were able to mitigate that risk quite rapidly with WhiteSpace Health. And the ongoing maintenance and support would be an additional challenge we didn’t want to take on.

Getting immediate access to trends for each client has been invaluable. We watch each payer to see who is paying fastest, who has the most denials, which are gaining and losing market share for each facility and across the portfolio – and so much more. This information helps SNF administrators deeply understand their business and adjust based on ongoing information about market conditions.

As a start up within the larger PointClickCare organization, RCM services need data to service our customers, and our customers benefit from the transparency to their RCM workstream health. They really like having access to their revenue cycle whenever they want it.

We use data and analytics during the sales process. It is a great starting point! Since we are selling to the existing PointClickCare customer base, we secure permission to perform a data analysis of the client’s revenue cycle. We can report on operations, risk, payer metrics to give them a baseline of their performance. We show them where they are doing well, where challenges exist and what we can do to resolve them. It helps our business too since we go at risk. We only get paid when cash is collected, and an accurate analysis helps us understand whether this is a good book of business or if it is too risky.

Sometimes the analysis of our client’s operational constraints limits the amount of success that can be achieved. It usually comes down to willingness to embrace change and re-designing process to make them more effective.

Good data is essential to effective, continuous improvement and high-quality reporting. If you don’t transform your data into business insights, you will definitely miss out on opportunities.